Plastic Surgery: Breast Reconstruction

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Introduction

Surgical therapy of breast cancer remains not only an important therapeutic mainstay but has also evolved as common prophylactic intervention. Although the techniques of local excision and mastectomy have changed since Halsted’s time, significant disfigurement may still occur. Breast reconstruction can profoundly help a woman’s healing and self-image as she is treated for breast cancer. The Women’s Health and Cancer Rights Act of 1988 mandates insurance coverage of breast reconstruction. Advancement in implant technology and autologous reconstruction techniques have vastly expanded the option breast cancer patients have for reconstruction. The surgeon should be familiar with the anatomy, indications, and contraindications for surgery and an overview of a variety of breast reconstruction options.

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Relevant Anatomy for Reconstruction

A

Vascular Supply ( Fig. 68.1 )

1.
Internal mammary vessels
2.
Thoracoacromial trunk vessels
3.
Lateral thoracic vessels
4.
Thoracodorsal vessels
5.
Intercostal perforators

B

Innervation

1.
Supraclavicular nerve
2.
Intercostobrachial nerve
3.
Anteromedial intercostal nerves

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Preoperative Evaluation

A

Goals of Reconstruction

1.
Desire for natural-appearing breast mound
- a.
  Ample breast volume
- b.
  Appropriate projection
2.
Optimization of skin envelope reconstruction
- a.
  Skin-sparing mastectomy—conserving skin if it does not compromise the oncologic treatment will improve the ultimate aesthetic outcome.
- b.
  Non–skin-sparing mastectomy—leads to techniques of expansion versus autologous tissue transfer
3.
Symmetry
- a.
  Patient may need augmentation or reduction of contralateral breast.
- b.
  Some patients choose prophylactic mastectomy of disease-free contralateral breast to prevent new primary disease, which can improve symmetric outcome during reconstruction.
4.
Nipple areolar complex reconstruction
- a.
  Matching pigmentation to contralateral breast
- b.
  Nipple projection corresponding to contralateral breast

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